Victor Royale

Allegation investigated: Resident did not receive proper room change notice

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Administrator Peter Babaian, Assistant Administrator Alice Nazarian, Staff 1 (S1) and Residents 1-5 (R1-5). LPA requested and received copies of Staff and Resident Rosters. LPA reviewed R1's file and obtained copies the following documents: Admission Agreement, Resident Appraisal dated 1/1/21, Identification and Emergency Information dated 3/5/21, Physician's Report for Residential Care Facilities for the Elderly (RCFE) LIC602A dated 5/19/21, Appraisal/ Needs and Services Plan dated 1/1/21 and 1/1/22, Two letters addressed to R1 dated 3/10/22 and 3/15/22, Unusual Incident/ Injury Report LIC624 dated 2/28/22 and 3/25/21. LPA also conducted a tour of facility which included observations of common areas, lobby, Resident Cottage 1511 and bathroom. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Resident did not receive proper room change notice, it is alleged that facility resident received a letter on 3/10/22 informing them that they will be relocated to another room in the facility in a week. It is alleged that the relocation is not due to any emergency. It is also alleged that the facility changed the notice of relocation from one week to 30 days due to resident's request for proper notice and resident personal rights. It is also alleged that facility administrator told resident that if anything happens in the 30 days the resident would be sued. Interview conducted with Administrator Babaian revealed that R1's physical condition has recently severely declined. He stated that R1 has been observed to have a strong limp and due to that R1 has to hold on to the walls while walking around the facility. He stated that R1 fell on 2/28/22 while coming in to the facility. Administrator stated that facility nurse offered R1 a walker which the resident took and has been see to use while in the facility but does not use when going out of the facility. Administrator stated that R1 refuses to be reassessed by the facility doctor and insisted on going to their doctor. Administrator stated that R1 was provided with a Physician's Report for Residential Care Facilities for the Elderly (RCFE) LIC602A so that they can take to their doctor for completion but has not received a copy from R1 yet. Administrator denied telling R1 that they will be sued. Administrator stated that due to R1's recent change in physical condition it is highly unlikely that R1 would be able to physically respond or take appropriate action in relation to an emergency such as a fire danger which is the reason that the decision was made to move R1 to a non ambulatory room in the facility and proper notice was given to R1. Administrator stated that R1 was given a one week notice of room change but due to R1 complaining the notice was updated to 30 days which is proper notice to resident for a room change. Notice was served to R1 on 3/15/22 and change is to take effect on 4/15/22. Interview with S1 revealed that they have recently observed R1's physical condition to change drastically. S1 stated that for the past 6 months a change in the physical condition of R1 has been observed but the resident continuously declines to be seen by the facility doctor. S1 stated that R1's condition has worsened within the last four weeks and on 2/28/22 resident fell while coming into the facility. S1 offered R1 a walker which they use around the facility but do not want to use when going out. S1 stated that when R1 is not using the walker they hold on to the walls for balance. Interview with R1 revealed that they believe the facility is making up that they need a walker so that they can move resident out of their room which they have lived in for over 30 years. R1 also stated that they use the walker only when out of the facility and stated that they do not need the walker but only use it for comfort. Interviews with R2-5 revealed that they are properly notified of any changes by facility and stated that they do not have any concerns. LPA review of R1's Resident Appraisal revealed that R1 refuses to be seen by facility doctor and recent observation of resident is poor balance. LPA review of R1's Appraisal/ Needs and Services Plan dated 1/1/22 revealed that poor balance has been observed and R1 has been offered a walker or cane due to fall risk but R1 refuses to use them. During interview with R1, LPA observed resident to not be able to stand without finding balance, observed resident to hold on to hallway walls while walking through facility hallway and also try to hold on to a bush to find balance during interview. LPA observed a walker in R1's room. Based on interviews conducted with facility staff, facility residents and LPA observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Peter Babaian.the state’s words, verbatim · CDSS document, Mar 15, 2022 · control 28-AS-20220310140032

Allegation investigated: Facility is not keeping copies of the last 30 days of menus

Licensing Program Analyst (LPA) Trueman conducted a complaint visit to investigate the allegation listed above. LPA met with Administrator, Peter Babaian and explained the reason for the visit. The kitchen was toured at 12:45 PM along with Assistant Administrator Alice Mazarian and the menu for 2/27 to 3/5 was posted and a sufficient supply of perishables and non-perishables were observed. Reception desk was toured and included a binder containing menus. From 12:30 PM to 1:15 PM Staff S1- S4 were interviewed. From 1:10 PM to 1:30 PM Resident R 1 was interviewed telephonically. In regards to the allegation Facility is not keeping copies of the last 30 days of menus,during tour LPA observed a binder containing menus from 1/30 to 3/5. Staff interviewed stated binder is always kept with 6 weeks of past menus available for review and menu for current week is posted by dining room. Resident 1 stated that he wants to review past 30 days of menus and if there are 6 weeks in binder that is good moving forward. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 2, 2022 · control 28-AS-20220222160553

Allegation investigated: Facility administration is telling the resident he has to change his insurance to their insurance.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Peter Babaian and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters. LPA also reviewed Resident #1 (R1's) file and obtained copies of the following documents: Copy of Insurance Card, Physician's Report, ID Emergency Information, Resident Appraisal, and Needs & Services Plan. LPA also interviewed Staff #1 - Staff # 2 and Resident #1 (R1) - Resident #5 (R5). The investigation revealed the following: in regards to the allegation "facility administration is telling the resident he has to change his insurance to their insurance", it is alleged that facility administrators are telling a resident that he must change his insurance to the facility insurance company. It is alleged that this resident would lose his dental and vision insurance if the change is made and would have to pay out of pocket expenses to see his doctors. (CONTINUED ON 9099C) Unsubstantiated Interviews conducted with staff members all denied the allegation. Staff indicated that the facility does not offer their own insurance. Facility staff indicated resident could have possibly misunderstood staff. Staff provided different insurance options to resident to better serve their specific needs, however no changes have been made to any residents insurance coverage. LPA also spoke to resident in question who confirmed that facility staff have not made any changes to his insurance coverage. All staff members interviewed indicated that they are not forcing any resident to make changes to their insurance coverages. 5 out of 5 residents interviewed indicated that facility staff have not forced them to make any changes to their insurance coverage. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, clients, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 15, 2022 · control 28-AS-20220208095038

Allegation investigated: Lack of supervision resulting in inappropriate interactions between resident's.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Peter Babaian (Administrator) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the Staff schedule and Resident roster. LPA interviewed Staff #1 in the office at 10:20 am and interview Resident #2 and #3 in their bedrooms between 10:40 am to 11:10 am. In regards to the allegation: Lack of supervision resulting in inappropriate interactions between resident's. A review of the Staff schedule indicate Staff is sufficient on the date of the incident. There is one night staff on duty and 3 staff on call which can arrived to the facility within 10 minutes if notified. Interviews with Resident and Staff revealed that on the night of the incident, Resident #3 was in Resident #2's bedroom for a cigarette. There is no indication that Residents engaged in any type of inappropriate interactions. Continue to LIC9099C...... Unsubstantiated Based on LPA's record review and interviews, investigation revealed that: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Peter Babaian and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 7, 2022 · control 28-AS-20220203150134

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Administrator Peter Babaian and Assistant Administrator Alise Nazarian who assisted with the visit. The purpose of the visit was explained. Facility is licensed to serve 49 Non-Ambulatory residents; of which four (4) may be bedridden. Facility is approved to retain/accept six (6) hospice residents. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. LPA toured randomly selected residents rooms. All bedrooms were furnished with required furnitures. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations guidelines. Common areas such as the dining room, hallways, Activity / TV room, no smoking patio were inspected. All areas were clean and had the required furniture. There is a smoking area in the back of facility/ shaded outside patio. Continued 809C The kitchen was toured. All appliances were clean and operating properly. There was a sufficient amount of perishable and non-perishable food. Smoke and carbon detectors were in good repair. The fire extinguishers observed to be fully charged. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed 6 residents and 4 staff records. Residents' records were found to be complete and current. Staff files were reviewed and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jan 28, 2022

Allegation investigated: Resident was pushed by another resident. Staff allow residents to smoke inside the facility. Resident was not accorded a healthful accommodation

/22/2021 Licensing Program Analyst (LPA) Nina Galarza conducted an unannounced subsequent visit regarding the allegations listed above. LPA met with staff, Amy Smbatuni and stated the purpose of the visit. LPA later met with Administrator Peter Babaian and stated the purpose of the visit. On 12/15/2021 LPA toured the facility with Staff#1(S1). The investigation consisted of the following; On 12/15/2021, interviews with Administrator, Staff #1-5(S1-S5) and Residents #1-5(R1-R5). On 12/15/2021 LPA obtained copies of staff roster, resident roster, face sheet for R1-R5, admission agreement and house rules. On 12/22/2021, interviews with Administrator and R1- R5. On 12/22/21 LPA obtained copies of staff roster, resident roster, facility sketch, and notice of construction. CONTINUED 9099-C Unsubstantiated In regards to the allegation: "Staff allow residents to smoke inside the facility." On 12/15/21 Administrator was interviewed and denied the allegation. On 12/15/2021, S1-S5 were interviewed, (3) out of (5) staff denied the allegation and stated they would tell the Administrator if they were to see a resident smoking in their room. On 12/15/2021 R1-R5 were interviewed, (4) out of (5) residents stated they do not smoke in their room, have never seen anyone smoke in their room and that they are aware of house rules stating they cannot smoke in their room. In regards to the allegation: "Resident pushed by another resident": On 12/15/21 LPA interviewed Staff and Resident who were present during the time of incident and were not able to corroborate Resident pushed by another Resident. R1-R5 were interviewed on 12/15/2021. (3) out of (5) residents stated they have been pushed before, but staff do their best to separate residents who don't get along and mitigate future altercations. (5) out of (5) staff stated they do their best to separate residents who don't get along and mitigate future altercations. In regards to the allegation: "Resident was not accorded a healthful accommodation" On 12/22/21 LPA interviewed Administrator. Administrator denied the allegation and stated a sink was installed in the patio area adjacent to the restroom area for the purpose of washing your hands after using the restroom. On 12/22/2021 LPA interviewed R1-R5, (5) out of (5) residents have their own restroom to use and stated they only use the restroom in the main facility for emergency purposes only. (4) out of (5) residents stated washing their hands in the sink located in the patio area is acceptable. Based on LPA's interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Peter Babaian and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2021 · control 28-AS-20211209150317

Type of visit: Case Management - Deficiencies

On 12/22/2021 9:30 a.m. Licensing Program Analyst (LPA) , Nina Galarza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed on 12/15/2021 during a complaint investigation. LPA met with administrator, Peter Babian and stated the purpose of the visit. On 12/15/21 LPA toured facility with Staff#1 (S1). On 12/15/21 LPA observed: No screenings of COVID-19 for temperature or symptoms were done for visitors of the facility white picket fence on side of facility, adjacent to a walkway, with detached pieces of fence and broken pieces of fence wooden fence on side of facility, adjacent to a walkway, with broken pieces of wooden fence a wooden bench located in the back yard area with back support detached on one side. a wooden bench located in the back yard area with metal support in disrepair. window on door leading to back area with cracks in glass utility door on side of facility, adjacent to walkway and wooden fence, off door hinge water pipe on side of facility building, with a missing screw to secure water pipe in place bathroom fixture in room 1 of cottage 1511 in disrepair, missing base and bar of towel rack. door of room 1 in cottage 1511 with a crack missing bathroom tile inside shower of shared bathroom in cottage 1511 wall in room 4 of cottage 1511 with a crack window in room 3 of cottage 1511 with a crack CONTINUED 809-C window screen in room 3 of cottage 1511 in disrepair and bent out of shape window screen in bathroom of room 1 of cottage 1515 with a tear window screen in room 6 of cottage 1515 with a tear window screens in main facility in rooms 6,8,15,16,19,23, 29, 27, and bathroom window in room 2 with tears in screen night stand in room 2 of cottage 1511 with missing drawer handle wall in closet of room 3 of cottage 1515 in disrepair, with duct tape securing wall fixture wood tiles near room 4 of cottage 1515 in disrepair and lifting from floor planks of wood, metal chair, plastic chair, concrete dry wall, plastic bucket and plastic boxes blocking walkway on side of facility bags of sand blocking walkway to patio area. open paint cans outside of cottage 1511 closed paint cans in patio common area by vending machines window of shower area with mold Deficiencies cited under California Code of Regulations, refer 809-D Exit Interview conducted, copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 23, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities ...personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: On 12/15/2021 LPA observed no screenings of COVID-19 for temperature or symptoms were done for visitors of the facility. Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 22, 2021

Plan of correction: Administrator will provide proof of visitor log for temperature check and symptom check for COVID 19 and proof of staff training of how to screen visitors and residents for COVID-19 to LPA by POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jan 7, 2022

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: On 12/15/2021 LPA observed white picket fence on side of facility, adjacent to a walkway, with detached pieces of fence and broken pieces of fence wooden fence on side of facility, adjacent to a walkway, with broken pieces of wooden fence, a wooden bench located in the back yard area with back support detached on one side, a wooden bench located in the back yard area with metal support in disrepair. window on door leading to back area with cracks in glass, utility door on side of facility, adjacent to walkway and wooden fence, off door hinge, water pipe on side of facility building, with a missing screw to secure water pipe in place, bathroom fixture in room 1 of cottage 1511 in disrepair, missing base and bar of towel rack, door of room 1 in cottage 1511 with a crack, missing bathroom tile inside shower of shared bathroom in cottage 1511, wall in room 4 of cottage 1511 with a crack, window in room 3 of cottage 1511 with a crack. window of shower area with mold Based on observation, interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 22, 2021

Plan of correction: Administrator will repair or replace all items and send picture proof to LPA Nina Galarza by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(2) · Plan of correction due date: Dec 23, 2021

87307 Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. On 12/15/21 LPA observed open paint cans outside of cottage 1511 closed paint cans in patio common area by vending machines, which poses an immediate Health and Safety risk to persons in carethe state’s words, verbatim · CDSS document, Dec 22, 2021

Plan of correction: Administrator will remove all items and send picture proof to LPA Nina Galarza via email by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(d)(6) · Plan of correction due date: Dec 23, 2021

87307 Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by On 12/15/21 LPA observed planks of wood, metal chair, plastic chair, concrete, dry wall, plastic bucket and plastic boxes blocking walkway on side of facility, bags of sand blocking walkway to patio area, which poses an immediate Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 22, 2021

Plan of correction: Administrator will remove all items blocking walkways and send picture proof to LPA Nina Galarza via email by POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Jan 7, 2022

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: On 12/15/21 LPA observed window screen in room 3 of cottage 1511 in disrepair and bent out of shape, window screen in bathroom of room 1 of cottage 1515 with a tear window screen in room 6 of cottage 1515 with a tear, window screens in main facility in rooms 6,8,15,16,19,23, 29, 27, and bathroom window in room 2 with tears in screen. Based on observation, interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 22, 2021

Plan of correction: Administrator will repair or replace all items and send picture proof to LPA Nina Galarza by POC date

Allegation investigated: Resident changed another resident's diaper while in care Facility has inadequate record keeping Staff are not meeting the diapering needs of the residents Staff did not prevent a resident on resident altercation

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent complaint visit regarding the allegations listed above. LPA Spencer was met by administrator Peter Babaian and explained the purpose of today's visit. The investigation consisted of the following: During the initial visit on 7/20/21, LPA Spencer took a tour of the physical plant and interviewed the administrator, staff #1-4 (S1-S4) and residents #1-6 (R1-R6). LPA attempted to interview S5 but was unable to be reached and R2 was non-verbal so the interview was discontinued. LPA received copies of the staff roster, resident roster, and diapering logs for three (3) specified residents. During today's visit on 12/9/21, LPA Spencer interviewed staff #6 (S6), resident #7-9 (R7-R9), and collected copies of needs and services plan for two specified residents. ***See LIC9099C for continuation of this narrative*** Unsubstantiated The investigation revealed the following: Resident changed another resident's diaper while in care It was alleged that a resident changed another resident’s diaper due to staff not changing the resident’s diaper in a timely manner. Seven (7) out of eight (8) residents interviewed stated that they did not know of any incident like this. One (1) resident stated that resident R6 kept screaming in the middle of the night for staff to change the diaper, so the resident changed R6's diaper. R6 denied this, stating only staff have changed R6's diaper. All staff interviewed denied the allegation with one (1) staff stated that they were told by a resident that this happened but did not witness it or know if it's true. Facility has inadequate record keeping It was alleged that staff are not maintaining adequate records including diapering logs. LPA obtained a copy of diapering logs for 3 specified residents. Diapering logs included the date, time, and initial of staff that conducted the diaper change. LPA observed that the logs were maintained daily and logs indicated that diapering took place for residents throughout the day. Interviews with staff reveal that four (4) out of six (6) staff stated that record keeping of diapering was maintained, while two (2) out of six (6) stated that it was not maintained accurately by all staff. Residents interviewed were not aware of this. Staff are not meeting the diapering needs of the residents It was alleged that staff are not changing resident’s diapers when needed at each shift. A review of the diaper logs for 3 residents shows that diaper change logs are filled out and completed throughout the day. The administrator stated that diaper checks are done every 2 hours and residents are changed as needed. Staff on each shift are responsible to check and change diapers. Four (4) out of six (6) staff interviewed stated that all staff meet the diapering needs of residents, one (1) out of six (6) stated diapering needs were not met by nighttime staff, while one (1) was unsure regarding this issue. Four (4) out of eight (8) residents interviewed stated that their diapering needs are met, three (3) out of eight (8) stated that their diapering needs are not met at night, and one (1) was unsure and does not wear diapers. A review of the needs and services plans for the residents who stated that their diapering needs are not met show that they are continent and able to use the restroom on their own. ***Continued on LIC9099C*** Staff did not prevent a resident on resident altercation It was alleged that on 7/13/21, two (2) residents had a verbal altercation and staff did not intervene when informed by another resident about the incident. Interviews with residents reveal: one (1) out of (8) eight residents stated that staff did not intervene during the resident altercation, one (1) stated that staff sometimes intervene, while six (6) out of eight (8) residents interviewed stated that they were not aware of this incident but that staff do intervene during resident altercations. The two (2) residents allegedly involved in the altercation did not recall the incident. Four (4) out six (6) staff were not aware of this incident but state that staff do intervene in resident altercations, while two (2) out of six (6) staff stated that staff went to check on the residents but it had already de-escalated and did not develop into a serious incident. Based on interviews and records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the administrator, and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 9, 2021 · control 28-AS-20210715162136

Allegation investigated: Staff pushed resident.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint at the facility. Upon arrival, LPA met with Alise Nazarian and explained the purpose of the visit. Administrator Peter Babaian arrived a short time later and assisted with the complaint investigation. During today's visit, LPA obtained a copy of the Staff/Resident rosters and interviewed Staff #1 in the office at 9:39 am, interviewed Resident #1 in the office at 10:12 am, interviewed Residents #2 and #3 in the office between 10:56 am to 11:19 am and interviewed Staff #2 and #3 in the office via telephone between 11:34 am to 12:12 pm. In regards to the allegation: Staff pushed resident: LPA's interviews with Staff and Resident who were present during the time of incident was not able to corroborate Staff pushed Resident. Continue to LIC9099C........ Unsubstantiated Based on LPA's interviews, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted with Peter Babaian and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 8, 2021 · control 28-AS-20211103151811

Allegation investigated: Staff left resident in soiled clothing for an extended period of time.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint visit to address the above allegations. LPA met with Administrator Peter Babaian. The purpose of the visit was discussed. The investigation consisted of the following: On today's visit, LPA toured the physical plant, interviewed residents #1-#7 (R1-R7), and interviewed Staff #1-#6 (S1-S6). LPA also reviewed R1's facility file. The investigation revealed of the following: In regards to the allegation, "Staff left resident in soiled clothing for an extended period of time." it was alleged that on 10/23/21, it was observed that R1's diaper had not been changed and was left with soiled clothing. (6) of (6) staff interviewed denied the allegation. (7) of (7) clients interviewed could not corroborate the allegation. Interviews with staff show that R1 does wear a diaper but as a personal choice. Interviews state that R1 is able to use the restroom and staff frequently ask R1 if they would like assistance but R1 prefers to be in a diaper and use it instead of getting out of bed. Continued on LIC 9099-C Unsubstantiated Staff interviews do not show that R1 is left in soiled clothing and that staff do change resident clothing daily. R1 refused to be interviewed on todays visit. Review of R1's file does not show that R1 needs assistance with their toileting needs and their plan of care does not show that a diaper is necessary. Based on statements and interviews conducted with staff and clients as well as LPA observation, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Peter Babaian. A copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 4, 2021 · control 28-AS-20211027104935

Allegation investigated: Staff engaged in a physical altercation with a resident while in care

Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint investigation visit in regards to the allegation above. LPA was greeted by Peter Babaian and Alise Nazarian and explained the reason for todays visit. The investigation consisted of the following: On 8/27/2020, LPA Almaraz conducted telephonic interviews with Administrator, Staff #1-4, and Residents #1-4. LPA requested copies of: Staff and Resident Roster, Police report number and Incident Reports. LPA also requested video footage of the incident. On 9/15/2021, LPA requested files for Staff #2, Resident #1 and #5. LPA also attempted to interviewed Resident #5 but the resident no longer lives at the facility. The investigation revealed the following: Based on interviews conducted, on 8/19/2020, Staff #2 was near a reception area when Resident #1 came by and was standing near the area. Staff #2 stated that Resident #1 was trying to enter the back of the reception area and told Resident #1, resident could not go behind the counter and had to move. (Continued on an LIC9099-C) Substantiated Per Staff #2, the phone started ringing and Staff#2 tried to go behind the counter and Resident #1 was blocking Staff #2. Staff #2 stated it never touched Resident #1, but when Staff #2 tried to go in the reception area Staff #2 stated Resident #5 attacked Staff #2. Video footage showed Staff #2 walking behind Resident #1 and doing hand gestures to Resident #1 to move away and go away from the area. The video shows Staff #2 does this repeatedly until Resident #1 moved to a corner by the entrance to the reception area . When the resident was in the corner, Staff #2 grabbed Resident #1 by the arm and shoved the resident away from the corner causing the resident to bump into a piece of furniture which appears to be a table/dresser with a vase of flowers on top. The table/dresser and flower vase fell towards Resident #1 and caused the resident to lose balance and walk backwards till the resident dropped on one knee. The video shows Resident #5 come and push Staff #2, two times, walking towards Staff #2 and causing Staff #2 to walk backwards. Staff #2 then grabbed Resident #4's walking cane and swung the cane towards Resident #5. Resident #5 grabbed it while the cane was aim at Resident #5 and took it away from Staff #2. Resident #4 stated that Staff #2 grabbed the cane in an attempt to hit Resident #5. Administrator stated the Glendale Police Department was contacted and a police report was filed. Based on video observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D An exit Interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Sep 15, 2021 · control 28-AS-20200819155029

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 22, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... . This requirement was not met as evidence by: Staff #1 grabbed Resident #1 by the arm and shoved the resident away from the reception area causing the resident to hit the table/dresser and it falling towards the resident. Staff #1 also grabbed a walking cane from Resident #4 and swung the cane towards Resident #5.the state’s words, verbatim · CDSS document, Sep 15, 2021

Plan of correction: Adminstrator will conduct Elder Abuse/Personal Rights training with all staff. Administrator stated he will have a meeting with Staff #2 and give the staff a written warning. Administrator also conducted training on 10/2020 and will send all documentation to LPA Administrator will send proof of training conducted for this month, and from 10/2020 along with written warning issued to Staff #2.

Allegation investigated: Staff did not assist resident with receiving medication.

Licensing Program Analysts (LPAs) Cynthia Chan and Nune Margaryan conducted a complaint investigation for the allegation listed above. LPAs met with Alise Nazarian, Assistant Administrator and explained the purpose of the visit. LPAs interviewed the Administrator, Assistant Administrator, 3 Staff, and 6 Residents. LPAs obtained a copy of the Staff and Resident rosters, and documents for Resident #1 (R1): Face Sheet, Preplacement Appraisal Information, Physican's Report, Appraisal/Needs and Services Plan, Medication log from January - June 2021, and facility notes. Resident #1 has not returned to the facility since 6/11/21 and was not interviewed. In regards to allegation - Staff did not assist resident with receiving medication. According to interviews with the Administrator, Assistant Administrator, and 1 Staff, they were aware of Resident #1's (R1) refusal of medication. Staff interviewed noticed that R1's behavior was becoming more agressive than usual and the refusal of medications may have attributed to the behavior in the beginning of June. (Continue on LIC9099C) Unsubstantiated The other staff interviewed does not pass out medication so staff did not know if R1 was taking medications or not. Staff who passed medication to R1 indicated they often encouraged R1 to take the medication while observing R1 to ensure that the pills were swallowed. R1's medication refusal began as early as 6/5/21 for some of the medications as documented on the Medication Administration Record (MAR) logs. At the same time, staff started noticing the increased aggressive behaviors from R1. Staff stated they immediately informed the LVN and Assistant Administrator. Per Assistant Administrator, the doctor was contacted when R1 started refusing to take the medications. She also called to PET Team to evaluate R1's aggressive behavior when it occurred more frequently, however, the team determined R1 did not qualify as a danger to oneself or others so R1 remained at the facility. The next day, R1 continued to refuse medication and the behavior continued, which led to staff contacting the police. The police came to the facility and placed R1 on a 5150 hold. LPA interviewed R1's son who indicated that the facility called to informed him that R1 refused to take some of the medications which was possibly the cause of R1's outbursts. He was also aware that the physician was contacted and understood that the facility cannot force the medication on residents. It was determined that staff assisted R1 with medication and also took the appropriate steps when medication were refused. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights were discussed and left with the Administrator, Peter Babaian, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Jul 20, 2021 · control 28-AS-20210713094059

Allegation investigated: Facility is not conducting fire drills.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Alise Nazarian and explained the reason for the visit. Administrator Peter Babian arrived shortly thereafter. The investigation consisted of the following: LPA toured the facility and obtained Staff & Resident Rosters. LPA reviewed the LPA also interviewed the Administrator and Staff #1 - Staff #2. The investigation revealed the following: in regards to the allegation "facility is not conducting fire drills", it is alleged that since the facility was last cited for this same allegation back in 2020, the facility has only conducted 1 fire drill. Per interview with Administrator, the last drill was conducted on 04/23/21 in the afternoon shift. However, Administrator was unable to provide documentation of said drill. (CONTINUED ON 9099C) Substantiated Interviews conducted with S1 & S2 revealed that they do not recall the last time the facility conducted a drill. Therefore there was sufficient evidence to corroborate with this allegation. Based on LPA's observations and interviews which were conducted record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 3.2 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report was provided to Administrator along with appeal rights.the state’s words, verbatim · CDSS document, Jul 15, 2021 · control 28-AS-20210707161111

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Jul 29, 2021

Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Based on interview with Administrator, last drill was conducted on 04/23/21. However there was no documentation available of said drill.This poses a potential Health, Safety, and/or Personal Rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2021

Plan of correction: Administrator to ensure drills are being conducted quarterly for each shift and documented with all required information. Administrator to conduct a drill for each shift by POC due date and submit documentation of said drills.

Allegation investigated: Residents are not notified to participate in their appraisal needs and services plan.

Licensing Program Analysts (LPAs) Elizabeth Irra and Nune Margaryan conducted the initial 10-day complaint visit to investigate the above allegation. LPAs met with the Assistant Administrator and discussed the purpose of today's visit. The Facility Administrator arrived at approcximately 10:20 A.M. and assisted with this visit. During today's visit, LPAs interviewed the Assistant Administrator (S-1), Facility Administrator (S-2), Licensed Vocational Nurse (S-3), Activities Director (S-4) and Housekeeper (S-5). LPAs also interviewed Resident #1 (R-1) through Resident #5 (R-5) and reviewed Residents files. Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Residents are not notified to participate in their appraisal needs and services plan. During today's visit, LPAs interviewed the Assistant Administrator (S-1), Facility Administrator (S-2), Licensed Vocational Nurse (S-3), Activities Director (S-4) and Housekeeper (S-5). LPAs also interviewed Resident #1 (R-1) to Resident #5 (R-5) and reviewed Residents files. Staff interviews revealed that appraisal needs and services plans are developed by staff reporting directly to the Facility Administrator and/or the Assistant Administrator of what each Residents needs are. Staff interviews revealed that appraisal needs and services plans are not developed with the Residents being present. Staff interviews revealed that appraisal needs and services plans are developed and provided to the Residents by the Facility Administrator and/or Assistant Administrator after the development of the appraisal needs and services plan for review and signature. Resident interviews revealed that they were not aware nor have they participated in a appraisal needs and services plan meeting. Staff and Resident interviews corroborate this allegation. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency as per California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. An exit Interview was conducted with the Administrator, a copy of this report and Appeal Rights were providedthe state’s words, verbatim · CDSS document, Jul 7, 2021 · control 28-AS-20210629083147

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c) · Plan of correction due date: Jul 14, 2021

Reappraisals: The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency,if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This standard is not met as evidence by: Please refer to page (2) of the LIC 9099 report for details.the state’s words, verbatim · CDSS document, Jul 7, 2021

Plan of correction: Facility Administrator to ensure that Residents are participating in the development of any reappraisals including appraisal needs and services plan. Facility Administrator to submit a written statement as to how Residents will be participating in the development of any reappraisals including appraisal needs and services plan by POC due date of 07/14/2021.